Provider Demographics
NPI:1780193177
Name:BANTIS, SONDRA MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:SONDRA
Middle Name:MARIE
Last Name:BANTIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SONDRA
Other - Middle Name:MARIE
Other - Last Name:BANTIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:612-262-4258
Practice Address - Street 1:225 SMITH AVE N STE 500
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2545
Practice Address - Country:US
Practice Address - Phone:651-292-0007
Practice Address - Fax:651-241-2740
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9209588363LG0600X, 363L00000X
MN10225363LA2200X
IAH155677363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner